GW1-2022-05816_Well Construction - GW1_20220609

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHNNY BURR 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. fL I
A - 3098 ft. rL
NC Well Contractor Certification Number
15.OUTER CASING for tnttlfi-casedwells)OR LINER ifs licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. I "is
Company Name
16 INNER CASING OR'TUBING fizeothermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable we//construction permits(i.e.UC,County,State,Variance,etc.) 0.0 It. 27.0 ft. 2.0 i in. SCH 40 PVC
3.Well Use(check well use): ft. ft, in.
Water Supply Well: 17.SCREEN r
FROM TO DIAMETERI I.SLOT SIZE I THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public 27.0 ft' 52.0 ft- 2.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. R. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl atlon ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 fL 20.0 fL PORTtANDBENTONITE SLURRY
OMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PAC K ifa licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 25.0 ft' 52.0 ft- 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiUrock e,gmin size,etc.
0.0 ft. 6.0 fr• RED/ORANGE CLAY
4.Date Wells)Completed: 05/19/22 Well ID# SSLF-PZ-1 6.0 ft• 25.0 ft- BROWN SANDY CLAY
5a.Well Location: 25.0 ft' 35.0 It' BROWN SILTY CLAY
ALLEN STEAM STATION 35.0 ft- 52.0 ft- GRAY/BROWN SI �&N. Y Q ,
Facility/Owner Name Facility ID#(if applicable) ft. fL
253 PLANT ALLEN ROAD BELMONT 28012 rt. ft.
Physical Address,City,and Zip 11. ft.
GASTON 2L REMARKS •:�
County Parcel Identification No.(PIN) BENTONITE SEAL- 20.0-25.0 FEET DI Q13C)G
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
***PIEZOMETER***
(ifwell field,one lat/long is sufficient) 22.Certification: n,
350 11' 15.80" N 810 00' 38.22" W G�'"�/ 16u� 05/23/22
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(mere)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or I!JNo 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a copy
lJ this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under 411 remarks section or on the back of!Iris form.
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23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 52'0 (ft.
Far muhiple wells list all depths tfdii ferent(example-3(a 200'and 1 a 100� ) Submit this GW-1 within 30 days of well completion per the following:
25.0 24a. For All Wells: Original form ito Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSi,Raleigh,NC 27699-1617
If w ater level is above casing,use"-'"
11.Borehole diameter: 8.0 (in,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER j
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-16 1 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Fomn GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018